Lack of anti choking devices in care homes and restaurants
Health and Safety Executive received 2 coroners' reports about this hazard between 24 Jan 2025 and 10 Sept 2025.
They came from 2 different coroners in 2 coroner areas. A similar concern was raised again 1 time after the first warning.
A published response was found for 1 of the 1 earlier reports, stating 1 specific action.
The story, report by report
Spacing grows with the time between reports.
“[REDACTED], who has considerable experience working in health and social care, said she was concerned that there was not wider knowledge of the existence of these devices particularly for homes that have a high volume of residents with choking risks like Acorn Care Home.”
Original on judiciary.uk ↗ Health and Safety Executive responded, stating 1 specific action.Response (PDF) ↗
“I have set out below more detailed information on how health and safety incidents are regulated in the health and adult social care sectors in England and on regulatory responsibility in respect of medical devices.”
- 8 months later
Raised again · 1st time
Stuart Gilchrist↗
10 Sept 2025 · Lorraine Harris · East Riding of Yorkshire and Hull
Closely relatedConfidence 0.90 · higha different coroner“During the evidence it was heard that there is a device that may assist in incidents of choking, it was referred to as a LifeVac (this may be a trade name).”
Original on judiciary.uk ↗ Health and Safety Executive responded.Response (PDF) ↗Response (PDF) ↗
- All reports to Health and Safety Executive
Each row is one judged link between an earlier and a later report. Open a row to read both quotes, found word for word in the originals.
2025 → 2025Stuart Gilchrist8 months after Neville McKenzie · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight a lack of awareness about the availability and usefulness of anti‑choking devices in specific settings. The earlier report concerns care homes, while the later report concerns restaurants and food establishments.
Neville McKenzie · 24 Jan 2025
“[REDACTED], who has considerable experience working in health and social care, said she was concerned that there was not wider knowledge of the existence of these devices particularly for homes that have a high volume of residents with choking risks like Acorn Care Home.”
Original on judiciary.uk ↗ Stuart Gilchrist · 10 Sept 2025
“During the evidence it was heard that there is a device that may assist in incidents of choking, it was referred to as a LifeVac (this may be a trade name).”
Original on judiciary.uk ↗
Stated action
“I have set out below more detailed information on how health and safety incidents are regulated in the health and adult social care sectors in England and on regulatory responsibility in respect of medical devices.”
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
- Each report's concerns were extracted by Nemotron 3 Nano on Nebius Token Factory, each with a quote copied from the report.
- Concerns from reports to Health and Safety Executive at least six months apart were compared by meaning (Qwen3 embeddings) and wording (TF-IDF).
- The closest pairs were judged by Nemotron 3 Super with reasoning on. Only identical or closely related, with confidence of at least 0.70, are shown.
- Every quote was checked by code as an exact substring of the original text. Names of staff and family are redacted, and the deceased are named by report title only.
| Link | Meaning | Wording | Judge | Coroner |
|---|---|---|---|---|
| 2025 → 2025 | 0.76 | 0.13 | Closely related · 0.90 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
Next
Other chains for Health and Safety Executive
This shows that a similar concern was raised again after an earlier report. It does not say why, and it is not a finding about any organisation or person. To report an error, see the corrections route.